Lung cancer epidemiology, aetiology, clinical presentation, diagnosis and treatment презентация

Lung Cancer: Basic statistics
Over 37,500 new cases per year in UK
Over 33,000 deaths per year in UK
Commonest cause of death from cancer in UK (more than deaths from Breast and Colo-rectal cancers combined)
A quarter of all cancer deaths
Incidence falling (slowly) in Men ; Increasing in Women (more common than breast cancer as a cause of death)

Ma-In
Fe-In
Ma-Mo
Fe-Mo

Lung Cancer: Age distribution 2006 England and Wales

LUNG CANCER: Smoking
Smoking causes:
~90% of lung cancer deaths in men
~80% of lung cancer deaths in women
~20% of lung cancer cases in nonsmokers
One Third of all cancer deaths
(but over 4000 deaths per year in in never smokers)
35-year old male who smokes ≥25 cigarettes per day:
13% risk of dying from lung cancer before
age 75 (i.e. 1 in 7)
10% risk of dying from coronary disease
28% risk of dying from smoking-related disease

Constituents of Tobacco Smoke
Gases
Carbon Monoxide
Hydrogen Cyanide
Nitrogen Oxide, etc. etc.
Nicotine
Irritant substances
Carcinogens
Poly-Aromatic Hydrocarbons
N-Nitroso Compounds
Phenols
Arsenic
Fatty Acid Esters

LUNG CANCER
Risk factors other than smoking
COPD (relative risk 3 – 6 fold)
Asbestos
Radon (from mining or indoor exposure) ~ 1500 deaths / year
Other “occupational carcinogens”
Chloromethyl ether, chromium, nickel, arsenic
Diet (vitamins A, C, E, β-carotene deficiencies)
Genetic/familial factors (relative risk ~ 1.6)

LUNG CANCER: Symptoms
Primary tumor
Cough
Dyspnoea; bronchial obstruction, p.effusion, pneumonia, phrenic N paralysis
Wheezing
Hemoptysis
Chest pain
Postobstructive pneumonia
Weight Loss
Lethargy/Malaise
Regional metastases
Superior vena caval obstruction
Hoarseness (Left recurrent laryngeal nerve palsy)
Dyspnoea (Phrenic nerve palsy)
Dysphagia
Distant metastases
Bone pain/fractures
CNS symptoms (headache,
double vision, confusion etc.)

Superior Vena Cava Obstruction

LUNG CANCER:Paraneoplastic syndromes
Endocrine
- Hypercalcaemia
- ectopic ACTH secretion; Cushing’s syndrome
- Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
- Carcinoid syndrome
- Gynaecomastia
Neurologic
- Encephalopathy, myelopathy
- Peripheral neuropathy, cerebellar degeneration
- Eaton-Lambert syndrome
Skeletal
- Finger Clubbing - Hypertrophic Pulmonary Osteoarthropathy
Haematological
- Anaemia
- Thrombocytosis
- Thrombocytopaenia
- Disseminated intravascular coagulation (DIC)
Cutaneous
- Hyperkeratosis
- Dermatomyositis
Other
- Nephrotic syndrome
- Secretion of vasoactive intestinal peptide with diarrhoea
- Anorexia or cachexia

Lung Cancer : Finger Clubbing

LUNG CANCER:
Local and distant spread
Brain
Draining lymph nodes
Pericardium
Lung
Pleura
Liver
Adrenals
Bone

Lung Cancer: Investigation
On first clinical suspicion:
Plain Chest X-Ray
Diagnosis and staging:
Serum Biochemistry (Sodium, Liver Function Tests, Calcium)
Imaging: Cross-sectional imaging: CT and PET scans. Isotope bone scan etc.
Tissue: Bronchoscopy (± Lymph node biopsy), CT guided needle biopsy, bronchial wash for cytology, Lymph Node Biopsy (neck), Mediastinoscopy, (Sputum Cytology), Pleural Biopsy/Cytology

LUNG CANCER
Chest X Ray

Fibreoptic Bronchoscopy

LUNG CANCER
Bronchoscopy

Lung cancer staging
TNM
T- tumor size.
N- lymph node involvement.
M- distant metastasis.
CT, PET, Biochemical tests, lymph node sampling, liver US, bone scan, BM aspiration or biopsy are needed for staging.
Bronchoscopy with EBUS or mediastinoscopy for upper mediastinal LN sampling.
Oesophageoscopy with endoscopic US for lower mediastinal LN sampling.

Transbronchial biopsy
Endoscopic Ultrasound
(CT biopsy)
Endoscopic Ultrasound
Endoscopic Ultrasound
Neck Ultrasound
Endobronchial
Ultrasound
Transbronchial
biopsy

RC Rintoul, Papworth Hospital
Endobronchial Ultrasound (EBUS)

RC Rintoul, Papworth Hospital
RC Rintoul, Papworth Hospital

NON-SMALL CELL LUNG CANCER
Stages at presentation
i.e. More than 2/3rds have inoperable disease at presentation
60%
Stage IV
10%
Stage I
9%
Stage II
21%
Stage III

SMALL CELL LUNG CANCER
Extent at presentation
i.e. 3/4 have metastatic disease at presentation
Limited
Disease
Extensive
Disease

Lung Cancer: Screening with low-dose CT scanning
9mm

Day 0
Day 36

Prognosis of lung cancer
Overall survival is poor: less than 10% live for 5 years
Survival (Prognosis) depends on:
Cell Type (Small Cell worse than Non-Small Cell)
Stage of Disease
Performance Status
Biochemical markers
Co-morbidities (e.g. Cardiac or chronic respiratory disease)
Overall Median Survival around 6 months
Survival worse in UK than in most other western countries

Lung cancer survival

Treatment of lung cancer
Surgery
Mostly for Non-Small Cell (less than 20% operable)
Radiotherapy
‘Radical’ - curative
‘Palliative’ - symptom control
Chemotherapy
Small Cell - potentially curative in a minority
Non-Small Cell - modest survival increase, symptom
control
Combination Therapy
Combination chemo-radiotherpy
‘Biological’ (‘Targeted’) therapies
Palliative Care

Treatment of Non-small cell lung cancer
Management of non-small cell lung cancer often involves multi-modality therapy
Palliative radiotherapy for local symptoms (eg cough, haemoptysis, airway obstruction, chest wall pain, bony metastases)
Radical radiotherapy for operable tumour in patient not fit for surgery.
Chemotherapy - ~ 50-60% response rates Modest improvement in survival; variable symptom relief
Combination chemo-radiotherapy important in locally advanced disease
‘Targeted’ agents – e.g. Epidermal Growth Factor Receptor (e.g. Erlotinib, Gefitinib) and Vascular Endothelial Growth Factor Inhibitors (e.g Bevacizumab)

Prognosis of non-small cell cancer
Up to 20% operable
Overall surgical survival 50% at 5 years
2/3 have metastatic disease at presentation

Prognosis of Non-small cell cancer
Survival by stage

Treatment and prognosis of small cell cancer
A systemic disease in >80% of cases
Rarely operable
~3 months median survival untreated
85-90% respond to combination chemotherapy
Approximately one year of added survival from chemotherapy
10-15% survive 2 years; less than 8% survive 5 years
Good symptom palliation with chemotherapy
Death from cerebral metastases common

Survival of small cell cancer by stage

Lung cancer palliative care
A disease with multiple symptoms and often poor survival - need for prompt treatment of symptoms
Need for early involvement of palliative care services
Specific palliation usually best done by appropriate specialist e.g respiratory physician, medical or clinical oncologist
Communication between, and co-ordination of, the various treatment agencies is vital. Patient held records may be useful.

What are the problems of lung cancer?
Late Diagnosis
Overall poor prognosis
Very symptomatic
Professional nihilism
Variable standards of care
Lack of public pressure